Epididymal tuberculosis pathogen Mycobacterium tuberculosis, Mycobacterium tuberculosis belongs to, the people were mainly Weiren pathogenic type and bovine tuberculosis. TB slender, slightly curved, two micro-blunt, developmental growth period Duocheng branch-like, and sometimes showed filamentous, rod-like. Human-type Mycobacterium tuberculosis, strictly aerobic, mainly feed on the cells, not easy to stain, but stained by the fuchsin heated, using acid alcohol rinse will not be able to make bleaching, it is called acid-fast bacilli. Bacteria can occur even under adverse conditions, variants, loss of cell wall, so called L-TB. TB Yin grow slowly, every 20 to 24 hours after breeding a generation of antibiotics on the reproductive growth of M. tuberculosis and effective, non-reproduction of M. tuberculosis, metabolism, antibiotics can not be blocked when in the application of antibiotics can survive.
Early lesions can be seen under light microscope epididymal duct containing exfoliated epithelial cells. WBC and a large number of Mycobacterium tuberculosis, followed by tubular necrosis occurs, the formation of granuloma, cheese-like change and fibrosis. Can be seen even within the epididymal sperm granuloma. Hematogenous spread, the lesion is located in the first interstitial epididymis, showing multiple small miliary-like granuloma, and violation of epididymis tubes. Epididymis of the cheese-like change very quickly spread to the epididymis, the adhesion with the scrotum to form a cold abscess, prolonged unhealed.
Third, the pathogenesis of
The most obvious clinical TB is the male reproductive system epididymal tuberculosis, the results from the pathological point of view, the site is the most common prostate, epididymis tuberculosis may be the primary tumor in the prostate, epididymis, tail of TB has always been considered by the prostate, retrograde infection of the vas deferens caused by the possibility of hematogenous spread widely. Epididymal tuberculosis patients are sometimes the only symptom, urinary tract imaging examination and urine cultures were negative for TB, while the epididymis, sinus disease and Mycobacterium tuberculosis can be cultivated. Therefore, whether it is from Epididymal Tuberculosis Genitourinary Tuberculosis is primarily spread by the original infections caused by blood lines, there is also controversy, both can cause, but what is the main, to be further studied.
4, clinical manifestations
Epididymal tuberculosis usually develops slowly, the gradual enlargement of the epididymis, no significant pain, swelling of the epididymis, scrotal adhesion formation with cold abscess cold abscess, such as secondary infection, then the local swelling and heat pain, abscess and ulceration Liou Publishing liquid and dry Cool necrosis substances, the formation of sinus. Individual patients rapid onset, fever, pain, scrotum increases rapidly, similar to acute epididymitis, until after the inflammation subsided, leaving the sclerosis, skin adhesion, scrotal sinus. Epididymal tuberculosis tenderness more obvious, serious epididymis, testis boundaries unclear, vas deferens thickening, showing bead-like, occasionally a small amount of hydrocele, digital rectal examination, the prostate induration.
5, diagnosis and differential diagnosis of
Epididymal tuberculosis diagnosis in general no difficulty, if the typical epididymal induration, skin adhesion, sinus, and bead-like vas deferens lesions, diagnosis, as can be determined. But early and acute onset of epididymal tuberculosis misdiagnosed. Early epididymal tuberculosis should be identified with chronic epididymitis, chronic epididymitis pain more apparent, often repeated episodes of acute seizures and a history of tuberculosis epididymal mass than the hard, big and little formation of the limitations of induration, not the formation of sinus and no skin adhesion and the beaded-like changes in the vas deferens. Gonococcal infection gonococcal epididymitis have a history of more acute onset, partial red, swelling, heat, pain, purulent secretions within the urethra, which can be found in the intracellular gram-negative meningitis, urinary tract secretions by polymerase chain reaction (PCR) can be found in the unique amino acid sequence of Neisseria gonorrhoeae. Epididymitis caused by chlamydia may also cause a similar-gonococcal acute epididymitis, patients have a history of non-gonococcal urethritis, urethral discharge more than the thin white. Scrotum filariasis can sometimes be confused with tuberculous epididymitis, filariasis, caused by the infiltration and induration in the epididymis, spermatic cord in the vicinity, and epididymis can be separated from filariasis sclerosis is often greater in the short term changes in of tuberculosis is changing very slowly, and filariasis are regional, patients may also have rubber-swelling and the chylous hydrocele. The normal epididymis is sometimes misdiagnosed as epididymal tuberculosis, epididymal head and tail slightly larger or slightly harder is a normal phenomenon, if there is no infiltration or sclerosis and can not confirm the diagnosis can be followed up for observation.
Treatment should pay attention to rest, nutrition, avoid fatigue.
(A) drug treatment
The suppression and killing of the role of Mycobacterium tuberculosis, can eliminate the growth of strong inside and outside cells, M. tuberculosis, but the metabolism is very slow and intermittent reproduction of bacteria, its bactericidal effect than rifampicin, right inside the acidic environment of macrophages in Mycobacterium tuberculosis is not as good as PZA. Good oral absorption, low toxicity, can be long-term use, isoniazid molecules small, widely distributed in the body, tissue concentrations and plasma concentrations of the same, the drug concentration in various tissues, including the cheese inside the lesions and macrophages concentrations were higher than the concentration required to kill bacteria. Isoniazid metabolism in the liver and its metabolic pathway through B Wan-oriented and intrahepatic P450 oxidase system decomposition. The main side effects of peripheral neuritis and hepatitis, the incidence of neuritis drug dose-related, long-term drug isoniazid can increase serum transaminases should have regular check liver function, if aminotransferase more than five times the normal should be withdrawal, stop After the restore drug, isoniazid can cause the spirit of excitement, paresthesia, optic atrophy.
Rifampicin soil from the Mediterranean after its separation silk Abamectin in 1965, synthesis, rifampicin can inhibit the TB of the RNA polymerase of M. tuberculosis has a strong killing effect. Rifampicin for the fat-soluble, can penetrate the cell membrane into the macrophage to kill intracellular bacteria, can enter the low oxygen tension cheese-like lesions, killing a low metabolism, growth, slow and intermittent reproduction of M. tuberculosis. Oral absorption of sound, organization penetration and tissue drug concentrations often exceed plasma concentrations. Side-effects of rifampicin in general mild and even can cause nausea, vomiting, skin syndrome mostly occurs in the early drug use, drug use occurred after 2 ~ 3 hours in order to face the most common skin red, itching, eye redness, tearing, if sustained attack , can be desensitization therapy. Medication during the period, urine and body fluids may become red, should be to enable patients to understand.
PZA for the nicotinic acid amine derivatives, synthesized in 1952, human-type Mycobacterium tuberculosis has bactericidal effect. Mycobacterium tuberculosis within macrophages division and metabolism is slow, showing latent state, and macrophages within the pH value is low, the impact of anti-TB drugs, sterilization, bacteria difficult to kill by other anti-TB drugs are the root causes of relapse, The PZA is right inside the acidic environment of macrophages in M. tuberculosis, has a special role in killing. Mycobacterium bovis is resistant to its. PzA excreted from the urine, half-life of 9 hours. Such as the daily dose is less than 2g, and the different tobacco navel, rifampicin combination, liver toxicity is not significant, daily doses greater than 3g, while a significant increase in liver toxicity. PZA metabolites compete with uric acid, inhibit the excretion of uric acid, it can increase uric acid in the body, causing joint pain.
Have bactericidal effect against Mycobacterium tuberculosis, can impair cell protein synthesis, soon after intramuscular injection into the tissue and can be empty and the cheese into the nodule-like tissue, but can not enter the cells can only kill extracellular M. tuberculosis. Streptomycin by glomerular filtration from the urine discharge. 1g intramuscular injection, the urinary concentrations of up to 200 ~ 400 tons / hour, the minimum inhibitory concentration can be maintained for 24 hours. PH7.8 when the efficacy of streptomycin in the best index of less than 6.0 when the hydrogen ion effect decreased significantly, so for the treatment of genito-urinary tuberculosis, are also basic drugs to improve the oral pH. Renal dysfunction, the accumulation prone to poisoning, the main toxicity is the impact of the eighth cranial nerve, there can still be restored dizziness, such as the timely withdrawal, deafness are often used for permanent use should be closely observed. Streptomycin toxicity of individual differences larger, individual patients can be injected a few days, so this appeared after injection of tinnitus and ear abnormalities within the sense of feeling and plug, shall be immediately discontinued. This drug can cause an allergic reaction, it should be done Minpi test before use.
Ethambutol has a bactericidal effect, can prevent the emergence of isoniazid-resistant strains, and can kill the cells inside and outside of the Mycobacterium tuberculosis resistant to isoniazid and streptomycin, but with isoniazid, rifampicin combined with When no significant increase in efficacy, oral absorption of a good B rubber-butanol, in vivo distribution of a wide variety of minimum inhibitory concentration of 1 ~ 2 Yan g / ml, 80% is excreted in urine, renal function was normal when the role of non-accumulation. The main toxicity of retrobulbar optic neuritis, manifested as blurred vision, central dark point, can not distinguish colors, mostly occurs in the treatment of 2 months later, but the toxicity is reversible after discontinuation can be resumed, toxic reaction and dose-related, according to 15mg/kg dose toxicity is rare, treatment should be every 6 weeks during perimetry.
6. For ammonia acid
Have antimicrobial effect against Mycobacterium tuberculosis, oral absorption of sound, adult medication 4g, after a ~ 2 hours up to 7 ~ 8 plasma peak Yan g / ml, then gradually declined, mainly in the liver of the ammonia acid metabolism by acetylation The main side effects were gastrointestinal symptoms, nausea, vomiting, anorexia, abdominal pain, diarrhea, can also cause secondary reduction of folic acid and giant mother anemia, taking on the ammonia acid, approximately 5% ~ 10% of patients allergic reaction occurs, the performance of fever, skin-yen and keratitis. Hepatitis may cause allergic reactions, often in the treatment of 3 months after the emergence of hepatitis occurred ago, often the drug allergy symptoms. As the new and more effective drugs have appeared on the ammonia acid has been used as second-line drugs.
Currently isoniazid, rifampicin, PZA, streptomycin, and B n-butanol as the first line of rubber anti-TB drugs, the application of these drugs in treatment of tubercular, 6 months can be the eradication of tuberculosis. Ze Xu past two years, compared to significantly shorten the course of treatment, so called "short-course chemotherapy." Bactericidal effect of short-course chemotherapy is not only good, disease recurrence rate is very low, the International Anti-Tuberculosis Association in 1988 recommended to the world short-course chemotherapy programs. A small number of patients with short-course chemotherapy after the recurrence or treatment failure, the failure of one of the main resistance to tuberculosis, while the multi-drug resistance gene mutation occurs as a TB.
(B) surgical treatment
Epididymal tuberculosis drug treatment early can be cured. If the local dry-TB necrosis serious, involving the testicles, and a large abscess formation of lesions or drug treatment was not obvious, then the possible removal of the epididymis. If there is testicular lesions, lesions close to the epididymis, testis part can be removed with the epididymis. Surgery should be kept in testis. After excision of the epididymis, seminal vesicle and prostate to gradually heal over TB.